Patient Access and 1-Year Outcomes of Percutaneous Coronary Intervention Facilities with and without On-Site Cardiothoracic Surgery: Insights from the VA CART Program
Background—The safety of percutaneous coronary intervention (PCI) at medical facilities without on-site cardiothoracic (CT) surgery has been established in clinical trials. However, the comparative effectiveness of this strategy in real world practice, including impact on patient access and outcomes, is uncertain. The Veterans Affairs (VA) health care system has employed this strategy, with strict quality oversight, since 2005, and can provide insight into this question.
Methods and Results—Among 24,387 patients receiving PCI at VA facilities between October 2007 and September 2010, 6,616 (27.1%) patients underwent PCI at facilities (n=18) without on-site CT surgery. Patient "drive time" (as a proxy for access), procedural complications, 1-year mortality, myocardial infarction (MI), and rates of subsequent revascularization procedures were compared by facility. Results were stratified by procedural indication (STEMI vs. NSTEMI/UA vs. elective), and PCI volume. With the inclusion of PCI facilities without on-site CT surgery, median patient drive time to the nearest PCI facility decreased by 90.8 minutes (p-value <0.001). Procedural need for emergent CABG and mortality rates were low and similar between facilities. Adjusted 1-year mortality and MI rates were similar between facilities (HR in PCI facilities without relative to those with on-site CT surgery 1.02, 95% CI 0.87, 1.2), and not modified by either PCI indication or PCI volume. Subsequent revascularization rates were higher at sites without on-site CT surgery facilities (HR 1.21, 95% CI 1.03, 1.42).
Conclusions—This study suggests that providing PCI facilities without on-site CT surgery in an integrated health care system with quality oversight improves patient access without comprising procedural or 1-year outcomes.
- Received March 13, 2014.
- Revision received May 12, 2014.
- Accepted July 7, 2014.